Tanglewood Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to accurately assess and document that Resident (R) 30 had a terminal condition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of stomach cancer, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure, and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition and required set-up assistance with toileting, and upper body dressing. R30 was independent with personal hygiene, mobility, transfers, and ambulation. The MDS noted R30 had no behaviors and received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 13 residents with two residents reviewed for treatment of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 received appropriate prompt treatment to promote healing and prevent worsening of a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The facility also failed to ensure R43 had nutritional measures and a pressure reducing device for her wheelchair in place. This placed R7 and R43 at risk for delayed healing and or increased risk for pressure ulcers. Findings included: - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 45 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care. This placed the resident at risk for urinary tract infections (UTI-an infection in any part of the urinary system) and other catheter-related complications. Findings included: - R45's Electronic Medical Record (EMR) documented diagnoses of acute respiratory failure with hypoxia (inadequate supply of oxygen), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), altered mental status, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for enteral feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube) management. Based on observation, record review, and interview the facility failed to ensure that Resident (R) 7 had a flush order for pre and post-bolus (a method of tube feeding that involves giving a patient a large amount of liquid formula through a feeding tube all at once) via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed R7 at risk of G-tube complications and adverse reactions including dehydration (not enough fluids) and fluid overload. Findings included: - The electronic medical record (EMR) for R7 documented diagnosis of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), respiratory failure (a condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents, with three reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30 had physician orders for oxygen therapy and failed to provide direction to staff for the cleaning, storage, and dispensing of oxygen. The facility failed to ensure R7 had a physician's order for his oxygen and further failed to store R7's and R45's respiratory equipment in a sanitary manner. This placed the residents at risk for increased respiratory infections and other related complications. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of stomach cancer, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 49 residents. The sample included 13 residents with Resident (R) 19 reviewed for pain management. Based on observation, record review, and interview, the facility failed to ensure R19 had her physician ordered Norco (a combination pain medication of opioid pain reliever hydrocodone and non-opioid pain reliever acetaminophen) medication available for administration as scheduled for pain management, which resulted in R19 missing a scheduled dialysis (a procedure where impurities or wastes are removed from the blood) appointment. This placed R19 at risk of complications related to unmanaged pain. Findings included: - R19's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS) dated 07/05/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 49 residents. The sample included 13 residents with one resident reviewed for dialysis for dialysis (a procedure where impurities or wastes were removed from the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services regarding Resident (R) 19's health status with each procedure. This deficient practice placed R19 at risk for complications related to dialysis. Findings included: - R19's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS) dated 07/05/24 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R19 utilized a wheelchair for mobility and required moderate to maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents, with six reviewed for behaviors. Based on observation, record review, and interview, the facility failed to immediately involve the physician and provide supportive mental health services to attain Resident (R) 30's highest practicable mental and psychosocial well-being after he made statements of self-harm. This placed the resident at risk for unmet mental health care needs and related complications. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of stomach cancer, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition. He required set-up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that staff failed to follow the physician's orders to administer insulin (medications used to help reduce the amount of sugar present in the blood) to Resident (R) 44. This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R44 documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary tract infection (UTI-an infection in any part of the urinary system), and lymphedema (swelling caused by accumulation of lymph fluid). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 13 residents with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19's as-needed antihypertensive (a class of medication used to treat high blood pressure) medication hydralazine was given per physician-ordered parameters. The facility failed to ensure R44's insulin (a hormone that lowers the level of glucose in the blood) was administered as directed. This placed these residents at risk of medication-related complications and possible adverse reactions. Findings included: - R19's Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN- elevated blood pressure), end-stage renal disease (ESRD-a terminal disease of the kidneys), and type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS) dated 07/05/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to hold food at a safe temperature for Resident (R) 36's room tray. This placed the resident at risk for foodborne illness. Findings included: - R36's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), atrial heart) flutter, muscle weakness, and need for assistance with personal care. The Quarterly Minimum Data Set, dated 10/03/24, documented R36 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or exhibited behaviors. R36 had no functional range of motion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 37 received thickened liquids per his orders. This placed R37 at risk of complications of aspiration (inhaling liquid or food into the lungs). Findings included: - R37 Electronic Medical Record (EMR) documented diagnosis of hypertension (HTN-elevated blood pressure), alcohol abuse, tobacco use, delirium (sudden severe confusion, disorientation, and restlessness) due to known physiological conditions, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), cerebral aneurysm (weakening area in an artery), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 44 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all residents who reside in the facility at risk of lack of assessments and inappropriate care. Findings included: - Upon review of Payroll Based Journal (PBJ-a required detailed information submitted by nursing homes of staffing required from Centers of Medicare an Medicaid Services [CMS]) RN eight-hour coverage on 07/09/22, 07/10/22, 07/23/22, 07/24/22, 08/06/22, 08/07/22, 08/20/22, 08/21/22, 09/03/22, 09/04/22, 09/10/22, 09/11/22, 09/17/22, 10/01/22, 10/02/22, 10/15/22, 10/22/22, 11/05/22, 11/06/22, 11/19/22, 11/20/22, 12/03/22, 12/17/22, 12/18/22, 12/22/22, 12/26/22, and 12/27/22. On 04/17/23 at 09:42 AM, Administrative Staff A stated the Director of Nursing worked the opposite weekends or whenever the RN needed off to cover the shift. Administrative Staff A further stated there was not documentation to verify her hours as she does not clock in. Upon request, a policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 44 residents. The sample included 14 residents with no COVID (an acute respiratory illness capable of producing severe respiratory complications) positive residents identified. Based on observation, record review and interview the facility respond to the high county transmission rates for COVID when the facility failed to ensure facility vendors wore masks in the facility to protect and prevent COVID transmission for the 44 residents residing in the facility. Findings included: - On 04/10/23 at 08:30AM, upon entrance into the facility signage on the front door stated, Shawnee County Community Transmission Levels are HIGH a mask is required. On 04/10/23 at 09:40 AM, observation revealed a vendor in facility on the main hallway. Further observation revealed the vendor pulling a small cart down the hallway. The vendor was not wearing a mask. On 04/10/23 at 09:50 AM, observation revealed Administrative Nurse D spoke with the vendor. On 04/10/23 at 11:00 AM, the vendor stated he was in the facility to repair a medication cart. He verified he checked in at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to follow-up or resolve resident grievances, placing the residents at risk for unresolved concerns leading to decreased quality of life. Findings included: - On 04/11/23 at 10:00 AM, during private discussion with the residents of the resident council, residents verbalized an ongoing concern regarding not receiving baths or showers. Council members verbalized no resolution from the facility regarding the council's grievance. Review of the resident council meeting minutes for past year, revealed on 02/21/23 and 03/21/23, resident council expressed grievances regarding not receiving baths or showers. The council minutes lacked documentation of the facility's action or follow up with the council to resolve resident grievances. Review of the facility's grievance log lacked documentation of grievances verbalized by the council. Onsite observations for the duration of the survey revealed residents who appeared unclean, with unwashed hair,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents, with eight reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services as care planned for four sampled residents, Resident (R) 27, R29, R2, and R22. This placed the residents at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R27 documented diagnoses of dementia (progressive mental disorder characterized by failing memory), depression (abnormal emotional state characterized by exaggerated feelings of sadness), and dysphagia (difficulty swallowing). R27's Annual Minimum Data Set (MDS), dated [DATE], documented R27 had severely impaired cognition and required extensive assistance of bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further documented R27 received extensive assistance of one staff for bathing. The Care Plan, dated 04/10/23, documented R27 required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to ensure a consistent reconciliation of narcotic medications between shifts. This deficient practice placed created the risk for misappropriation and/or drug diversion. Findings included: - On 04/10/23 at 01:30PM, the Narcotic Count Sheet on the narcotic medication cart lacked evidence of reconciliation of narcotics. The following documentation was missing from the facility's Narcotic Count Sheet: 04/07/23 6 AM - 2 PM shift, No signature for oncoming nurse 04/07/23 2 PM- 10 PM shift, No signature for off-going nurse 04/08/23 6 AM - 2 PM shift, No signature for oncoming nurse 04/08/23 2 PM - 10 PM shift, No signature for oncoming nurse 04/08/23 10 PM- 6 AM shift, No signature for off-going nurse 04/09/23 6 AM - 2 PM shift, No signature for oncoming nurse 04/09/23 2 PM - 10 PM shift, No signature for off-going nurse On 04/10/23 at 01:40 PM, Licensed Nurse (LN) G verified the missing documentation on the narcotic reconciliation count sheet.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one sampled resident, Resident (R) 18, who was unnecessarily exposed. This placed the resident at risk for undignified care and services. Findings included: - The Electronic Medical Record (EMR) for R18 documented diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods. R18's Quarterly Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview the facility failed to honor Resident (R) 8's preference to receive two showers a week. This deficient practice placed R8 at risk for decreased self-determination and impaired psychosocial well-being. Findings included: - The Medical Diagnosis section within R8's Electronic Medical Record included diagnoses of rheumatoid factor of multiple sites (chronic inflammatory disease that affected joints and other organ systems), unspecified dislocation of right hip, cervicalgia (pain in or around the spice beneath the head), reduced mobility, muscle wasting and atrophy, weakness, difficulty in walking, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and need for assistance with personal care. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had intact cognition, had not exhibited behaviors,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed keep Resident (R) 23's protected health information (PHI) private on a medication cart parked in the hallway next to the nurse's station, placing the affected resident at risk for impaired privacy. Finds included: - On 04/10/23 at 07:29 AM observation revealed a medication cart parked across from the nurse's station with a laptop computer sitting on the top; there were no staff present. The laptop computer screen had R23's PHI on the screen visible to all who passed by the medication cart. The information visualized included R23's date of birth , allergy information, code status, and medications. On 04/10/23 at 07:32 AM Certified Medication Aide (CMA) R approached the cart and reported the laptop screen should not have been visible. CMA R said it should be closed when not attended. On 04/18/23 at 10:40 AM Administrative Nurse D verified the medication cart laptop computer screen should be closed or information hidden as not to reveal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to report to the state agency a resident-to-resident altercation between two sampled residents, R29 and R22. This placed the resident's at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of vascular dementia with behavioral disturbances (caused by impaired supply of the brain), traumatic brain injury (caused by an outside force, usually a violent blow to the head), assistance with personal cares, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), depression (abnormal emotional state characterized by exaggerated feelings of sadness) and schizophrenia (a serious mental condition involving a breakdown on the relation between thought, emotion, and behavior). R29's Quarterly Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to investigate a fall for Resident (R) 17, who fell during transport to dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions), and the facility failed to investigate a resident-to-resident altercation between two sampled residents, R29 and R22. This placed the resident's at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), end stage renal disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - The Electronic Medical Record (EMR) for R26 documented diagnoses of edema, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), apraxia (inability to perform particular purposive actions, as a result of brain damage), seizures (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and hypertension (high blood pressure). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had intact cognition but had difficulty with new situations, R26 was dependent upon two staff for transfers, and required extensive assistance of two staff for bed mobility, dressing, and extensive assistance of one staff for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents, with one reviewed for edema (swelling). Based on observation, record review, and interview, the facility failed to apply the standards of practice as related to dependent edema when staff failed to elevate Resident (R)26's legs to decrease the edema in her legs. This placed the resident at risk for complications related to edema. Findings included: - The Electronic Medical Record (EMR) for R26 documented diagnoses of edema, hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), apraxia (inability to perform particular purposive actions, as a result of brain damage), seizures (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - The Electronic Medical Record (EMR) for R17 documented diagnoses of hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), end stage renal disease (kidney failure), diabetes mellitus type 2 (the body either doesn't; produce enough insulin or it resists insulin), and abnormal posture (abnormal positions of the body). R17's Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R17 had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene; R17 did not ambulate. The MDS further documented R17 had unsteady balance, had no functional impairment, and had two or more falls since admission or prior assessment. R17 was on dialysis (the process of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 14 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain physician ordered blood sugars for one sampled resident, Resident (R) 17, who received insulin (medication used to treat high blood glucose). This placed the resident at risk for complications related to high or low blood sugars. Findings included: - The Electronic Medical Record (EMR) for R17 documented diagnoses of hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness but without complete paralysis) following a cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting left dominant side, dysphagia (difficulty swallowing), end stage renal disease (kidney failure), diabetes mellitus type 2 (the body either doesn't; produce enough insulin or it resists insulin), and abnormal posture…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 14 residents with eight residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to ensure that bathing was provided for eight residents who required partial or complete assistance from staff for bathing. This deficient practice placed resident (R)8, R30, R43, R22, R37, R17, R40 and R94 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices and impaired psychosocial well-being. Findings included: - The electronic medical record (EMR) for R8 documented diagnoses of traumatic brain injury (brain dysfunction caused by a blow or jolt to the head), bipolar disorder (a major mental illness that caused people to have episodes of severe high and low moods), and psychoactive substance abuse with intoxication delirium (a condition that causes disturbances in focus and attention due to substance abuse). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 45 residents with one kitchen and one dining room. Based on observation, interviews, and record review, the facility failed to ensure sanitary equipment cleaning and food storage. This deficient practice placed residents at risk for food borne illnesses and food safety concerns. Findings Include: - During the initial inspection of the kitchen on 12/06/21 at 07:20 AM the facility's ice machine cleaning and maintenance log indicated that the last documented cleaning occurred on 09/18/2021. The machine had some brown stains on the opening area. An inspection of the freezer located inside the cooking area revealed two opened whipped topping piping bags setting directly on the bottom of the upper freezer unit. The bags were dated 12/06/2021 and contained 1/3 of the whipped topping inside them. The containers were opened, without a cover or barrier to protect the contents inside the bags. An inspection of the whipped topping containers stored in the lower refrigerator unit revealed them to be sealed and properly stored. In an interview on 12/06/21 at 07:30 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 45 residents. The sample included 14 residents, with three residents reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of the facility stay upon discharge from the facility for Resident (R) 45. This placed R45 at risk for impaired continuum of care. Findings included: - R45's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of multiple fractured ribs (broken bones), and hypertension (elevated blood pressure). No Minimum Data Set (MDS) was completed during R45's stay at the facility. No Care Area Assessment (CAA) was completed during R45's stay at the facility. R45's Care Plan dated 11/19/21 documented staff supervised R45 during activities as needed. Review of the EMR under Progress Notes tab documented on 11/19/21 at 01:47 PM R45 discharged home with current medication and treatment. R45 was to receive home health services with physical therapy, speech therapy and occupational therapy. She left by private vehicle accompanied by her spouse and son. All of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 45 residents. The sample included 14 with one reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to assess and remove hazards in the resident's environment resulting in a fall. This deficient practice placed the resident at increased risk for future injuries related to accidents and /or hazards. Findings included: - The electronic medical record review (EMR) documented the following diagnosis for R39: major depressive disorder (major mood disorder), type two diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), diverticulitis of small intestine (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), hyperlipidemia (condition of elevated blood lipid levels), Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents. The sample included 14 residents, with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to retain communication sheets which included information from the dialysis provider for Resident (R) 40, which had the potential for unwarranted and unidentified physical complications related to dialysis. Findings included: - R40's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), end stage (a terminal disease because of irreversible damage to vital tissues or organs) renal disease (inability of the kidneys to excrete wastes, concentrate urine and conserve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.